Healthcare Provider Details

I. General information

NPI: 1417485616
Provider Name (Legal Business Name): IVY LEAGUE ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MOUNT PLEASANT AVE STE E
DOVER NJ
07801-1630
US

IV. Provider business mailing address

600 MOUNT PLEASANT AVE STE E
DOVER NJ
07801-1630
US

V. Phone/Fax

Practice location:
  • Phone: 908-255-6200
  • Fax:
Mailing address:
  • Phone: 908-255-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JORGE G MENDEZ
Title or Position: MEMBER
Credential: MD
Phone: 908-255-6200